Chronic pelvic pain Gynecologists perspective Objectives

Chronic pelvic pain
Gynecologists perspective
A. El-Dabh, FRCOG, FACOG
Fairview Hospital
Cleveland Clinic
Objectives
Gynecologists work-up for CPP
 Common gynecological etiologies
 When Gynecologists refer patients to pain
management

CHRONIC pelvic pain
Gynecological literature

No universally accepted definition.
3 months duration
6 months duration
6 months cyclic or 3 months non
cyclic
Chronic pelvic pain in
Pain Management literature
Incomplete relief by previous treatments
 Pain out of proportion to tissue damage
 Loss of physical function
 Vegetative signs of depression
 Altered family dynamics
NB:
This is best known by GYNs as CPP SYNDROME

Pathophysiology of pain
In acute pain, a peripheral painful
stimulus from damaged or irritated tissue
is centrally perceived. This pain is
proportional to the damage or stimulus
 In CPPS, it is often difficult to find enough
pathology to explain the pain
 The pain stimulus-perception system is
often obscured by complicating emotional
factors

Scope of the problem of CPP
from a gynecological perspective

10% of gynecologists visits

40% of laparoscopies
Howard FM Obstet Gynecol Surv 1993 Jun;48(6):357-87
20% of hysterectomies done for benign
diseases

Farquhar CM; Steiner CA Obstet Gynecol 2002 Feb;99(2):229-34
Gynecologists role in CPP
1- Ruling out the coexistence of an acute
etiology for pain (eg strangulated hernia,
ruptured ovarian cyst)
2- Diagnosing and treating the underlying
condition that resulted in CPP (eg
endometriosis, IBS)
3- Diagnosing and referring patients with
genuine CPP syndrome
Scope of CPP
Gynecological disorders.
 GI.
 Urinary.
 Musculoskeletal
 Psychiatric and Psychological disorders.
 Pain processing disorders.

How do Gynecologists work up
patients with CPP?
History taking
Pain description by the patient;
 Duration
 Intensity
 Frequency
 Aggravating factors
 Relieving factors
 Relationship to BM, urination or SI
 Relationship to menses
History taking
Review of symptoms:
Particular attention to be paid to GI, GU,
reproductive, musculoskeletal or
psychoneuronal systems
 History of
Previous treatment especially surgeries
Drug or alcohol abuse
Sexual, physical or psychological abuse

Screening for depression/ abuse

Many screening methods

Three simple questions:
During the past month, have you felt down,
depressed or hopeless?
During the past month, have you felt little interest
or pleasure in doing things?
Have you ever been touched against your will?
Whooley MA; Avins AL; Miranda J; Browner WS J Gen Intern Med 1997 Jul;12(7):439-45
Clues, pointers
in pain description

Dull diffuse pain is usually visceral as the bowel
is symmetrically innervated
Abdominal visceral sensation in man. Ann Surg 1947; 126:709
Surg Gynecol Obstet 1949; 89:573
Somatic pain is localized
Cyclical pain related to menses is often caused
by endometriosis or adenomyosis
 Pain that started with pregnancy or shortly
thereafter is often musculoskeletal
 Dysmenorrhea and dyspareunia are often signs
of endometriosis


Clues, pointers
Referred pain is usually aching and
superficial
 Nerve entrapment pain is usually
described as hot, cold or as an electric
shock
 Pain associated by urge to void is often
caused by interstitial cystitis
 Pain associated by weight loss can be
associated with malignancy

Abdominal exam
Guarding , rigidity
 Ascites, organomegaly
 Palpation starting from the quadrant that
is least tender
 Particular attention to hernia sites,
inguinal, femoral, periumbulical and
incisional

Carnett’s sign



While supine, the patient is asked to raise her head or
raise both legs while the examining finger is on the
tender point
Increased tenderness with the rectus abdominus muscle
tightened is an indication for myofascial pain; hernia,
entrapped nerve or trigger point
Visceral pain should diminish with tightening of the
rectus muscle
Carnett, JB. Intercostal neuralgia as a cause of abdominal pain and tenderness.
Surgery, Gynecology & Obstetrics 1926; 42:625
Pelvic exam
Vulva
 Urethra
 Vagina and muscles
 Uterus
 Adnexae
 US ligaments

Vulvar examination
Particularly important in patients presenting with
vulvar pain or vulvodynia
 This pain may be described as burning, mild or
severe sensitivity, generalized or localized on the
vulva, provoked or unprovoked
 Pain is much exacerbated by touching the vulva
or vaginal entry
 The only physical sign often seen is sensitivity to
touch with a q tip

Urethra examination
Palpation of the urethra can often uncover
a diverticulum
 This may be the source of chronic pain
due to recurrent UTIs
 Rarely urethral diverticula harbor a stone

Palpation of the uterus
ADENOMYOSIS:
enlarged, soft and tender uterus
exam particularly helpful if before menses
 FIBROIDS:
enlarged, irregular, firm and nodular
uterus
Both conditions result in pelvic pain before and
with menses as well as heavy painful periods

Adnexal exam
The adnexae (ovaries and tubes) are
palpated to check for:
1- Enlargement; ovarian cysts or solid
tumors, benign or malignant
2- Tenderness, may be a sign of chronic
PID, endometriosis or pelvic adhesions
NB Pelvic congestion syndrome is a
controversial entity
Wadsworth J Br J Obstet Gynaecol. 1988 Feb;95(2):153-61
Uterine prolapse check





Most patients will complain of pain at the end of
the day or after prolonged standing
Pain may be accompanied by low backache
Traction on the protruding cervix will duplicate
the pain
On asking the patient to strain; the cervix,
bladder or the rectal wall will be seen protruding
down to or beyond the hymenal ring
Wearing a pessary will provide relief
Pelvic neuropathies

Iliohypogastric (T12, L1) and ilioinguinal (L1)nerves are
the most commonly affected

Genitofemoral Nerve disorders (L1, 2)
Patients will present with lower abd pain
descending into the genital area

Pudendal neuropathy (S1,2,3):
Patients will present with dyspareunia,
bladder pain, rectal pain and sitting pain
Weiss JM J Urol 2001 Dec;166(6):2226-31
IH
GF
P
II
Pelvic muscle palpation
Pyriformis/ Levator ani syndrome is not a
rare form of chronic pelvic pain
 Digital palpation of these muscles using a
single digit will feel these muscles
contracted and tender
 The anal wink reflex is often absent in
these patients.

Brief Orthopedic exam




Exaggerated lumbar lordosis
Pelvic tilt; distance between ASIS and
lateral malleolus bilaterally
Tender joints particularly the symphysis
pubis, sacro-iliac joints and the hip joints
Tender vertebrae indicating osteoarthritis
or prolapsed discs
Common etiologies for CPP
Endometriosis and CPP
Definition:
The presence of endometrial glands and
stroma outside the endometrial cavity and
uterine musculature
Symptoms
Can be associated with many distressing
and debilitating symptoms, such as pelvic
pain, severe dysmenorrhea, and
dyspareunia, or it may be asymptomatic
Endometriosis and CPP
Prevelance;

In general population is not known

12 to 32 % of patients undergoing laparoscopy for CPP

50% of teenagers with CPP

9 to 50% of patients undergoing laparoscopy for
infertility
Sangi-Haghpeykar H; Poindexter AN 3rd Obstet Gynecol 1995 Jun;85(6):98392
Chatman DL; Ward AB J Reprod Med 1982 Mar;27(3):156-60
Missmer et alAm J Epidemiol 2004 Oct 15;160(8):784-96
Endometriosis and CPP
Accurate diagnosis is made by laparoscopy
 Different often very subtle findings:
Typically powder burns or gunshot lesions
Can often have a variety of shapes and
colors, including clear, pink, brown, white or
yellow
 May be only seen as areas of scarring on the
peritoneal surface

Stegman et alFertil Steril. 2008 Jun;89(6):1632-6. Epub 2007 Jul 26
Challenges in diagnosing
endometriosis
Accurate diagnosis is dependant on the
size and location of the lesion and the
experience of the operator
 In one study comparing surgeons who did
less than 5 laparoscopies a year to others
who did between 27 and 99, the correct
diagnosis was made in 54% for the first
group versus and 99% for the second

Endometriosis and CPP
Treatment:
 Mainstay of treatment is surgical excision
of the implants
 TAH +/- BSO is reserved for older patients
with extensive disease
 Medical therapy for patients with mild or
recurrent disease. This includes BCP,
progestogens, GR analogs and off label
use of aromatase inhibitors
Pelvic congestion and CPP


Old diagnosis that has attracted new interest.
Proponents believe that ovarian or broad
ligaments veins dilatation can cause pain and
that embolizing these vessels relieves pain.
Beard et al Lancet 1984 Oct 27;2(8409):946-9
These reports are limited, lack control and are
not universally accepted.
 The role of pelvic congestion in CPP is currently
questionable

J Lancet 1987 Aug 15;2(8555):351-3
Urological causes of CPP
Chronic UTI
 Urinary calculi
 Interstitial cystitis
 Urethral syndrome

Interstitial cystitis or PBS

Painful bladder syndrome is the complaint
of suprapubic pain related to bladder
filling, accompanied by other symptoms
such as increased daytime and night-time
frequency, in the absence of proven
urinary infection or other obvious
pathology
Report from the Standardisation Sub-committee of the International
Continence Society. Neurourol Urodyn 2002; 21:167
Prevalence of IC or PBS
Because of the lack of clear definition,
prevalence varies widely between reports
 In patients with CPP, the prevalence was
quoted between 12 and 75%

Parsons CL; Bullen M; Kahn BS; Stanford EJ; Willems JJ Obstet Gynecol. 2001
Jul;98(1):127-32
Sant GR Urology. 2007 Apr;69(4 Suppl):S5-8
ISC/PBS
Etiology
 Not exactly understood
 Thought to be caused by a defect in the GAG layer lining
the bladder
 This layer makes the bladder wall impermeable to
bladder irritants
 Irritants penetrating the urothelium irritate the nerves
and muscles of the bladder wall resulting in tissue
damage, pain and hypersensitivity
The role of the urinary epithelium in the pathogenesis of interstitial
cystitis/prostatitis/urethritis. Parsons CL Urology. 2007 Apr;69(4 Suppl):S9-S16
Diagnosis of
ISC/PBS
On examination, tenderness over the
bladder base, pelvic floor or urethra
 Cystoscopy to rule out bladder pathology
 Hydrodistention with characteristic
glomerulations and Hunner’s ulcers

Potassium challenge test Bogart LM; Berry SH; Clemens JQ J Urol.
2007 Feb;177(2):450-6
Teichman JM; Parsons CL Urology. 2007 Apr;69(4Suppl):S41Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:430
GI causes of CPP
The intestines and the reproductive
organs share the same innervations.
 Common causes of GI CPP are:
IBS
Inflammatory Bowel disease
Diverticular disease
Colon cancer

IBS
Usually presents as abdominal pain or
chronic pelvic pain relieved by a BM with
altered bowel habits
 Etiology is unknown
 May be present in 50 to 80% of CPP pt

J Psychosom Obstet Gynaecol 1996 Mar;17(1):39-46
Rome criteria for IBS


12 wks in last 12 months of abdominal pain +2/3:
relieved by defecation
change in frequency of defecation
change in stool form or appearance
Symptoms that increase diagnostic accuracy
-abnormal stool frequency >3/d or <3/wk ,
-mucus
-bloating
Rome III diagnostic criteria* for irritable bowel syndrome. Longstreth, GF,et alGastroenterology 2006; 130:1480
Inflammatory bowel disease
Pain, distention and gas as in IBS
 Diarrhea and fever are often present.
- Diverticulitis: more common above 40
with LLQ pain
-Crohn’s disease: more common in
younger patients with RLQ pain
-Chronic appendicitis: controversial; if
present is rare

Hernias
Most common
in CPP

2
3
1
Inguinal hernias
Most common types of abdominal hernia
Indirect inguinal hernias:
-Develop at the internal Inguinal ring
-Are congenital but become obvious later
-Defect in closure of processus vaginalis
Direct inguinal hernias
Congenital or acquired weakness of muscle
on the posterior wall of the inguinal
canal
Pelvic adhesions and CPP
The relationship between CPP and the
presence of pelvic adhesions is poorly
defined
 Dense adhesions may limit organ mobility
resulting in visceral pain
 This has been shown in conscious
laparoscopic pain mapping pain

Howard FM, El-Minawi AM, Sanchez RA
Obstet Gynecol. 2000;96(6):934
Pelvic myofascial pain
AKA pelvic floor dysfunction, Levator
myalgia, Pelvic floor spasm, Myofascial
pelvic pain syndrome
 Prevalent but commonly overlooked cause
of CPP; 78% of CPP in one study *
 Symptoms are vague
 Flares are unexpected
 Manifestations are inconsistent
* Bassaly R et al, Int Urogynecol J. 2011:22(4):413-418

Pelvic myofascial pain
Diagnosis;
 Tight often band-like pelvic muscles felt on exam
 Palpating these muscles will reproduce the pain
Treatment
 Pelvic massage
 Trigger point injection
 Neuromodulation
Treatment of PMP syndrome
Therapeutic massage:
 Consists of vaginal manipulation of the
trigger-point muscle bundle
 In a study of 47 patients randomized
between vaginal myofascial vs general
massage, both given weekly for an hour
for 10 weeks, the improvement rate was
57% vs 21% J Urology. 2009;182(2):570-580
Treatment of PMP syndrome
Trigger point injections:
 Aim is to relax or anesthetize the tender points
in the muscles involved
 Mechanism of action is not known
 Ideal agent is not known
 Bupivacaine + Lidocaine + Triamcinolone
resulted in 72.2% improvement and 36% cure.
Langford et al Neurourol. 2007 (1):59-62

Botoxin A was found to be equally successful as
placebo in small series with significant
improvement in both groups.
Abbott et al Obstet Gynecol. 2006;108(4):915-923
Treatment of PMP syndrome
Neuromodulation:
 Direct conduction from a lead in the
sacrum
 Retrograde using percutaneous TNS
42% of patients reported at least 50%
decrease in pain after 12 weeks of weekly
30 min sessions. Van Balken et al Eur Urol. 2003:43(2):158-163
No placebo controlled studies
No FDA approval
Sacral neuromodulation
PTNS
Psychiatric and Psychological causes
of CPP
Depression
Physical and sexual abuse
Somatization
Hypochondriasis
Opioid seeking
Facticious and malingering






Am J Psychiatry 1988 Jan;145(1):75-80
Diagnostic and Statistical manual of Mental Disorders.
Primary Care Version. Fourth Edition ed. Washington DC 1995
Bapkin et al 1995Obstet Gynecol 1990 Jul;76(1):92-6
Investigations for patients with CPP
Complete blood count with differential
 Urinalysis
 Testing for Chlamydia and Gonorrhea
infection
 Pregnancy test

Gambone JC; Mittman BS; Munro MG; Scialli AR; Winkel CA Fertil Steril 2002
Nov;78(5):961-72
Imaging for CPP
Ultrasound useful for diagnosis of
 Ovarian cysts, and endometriomas
 Ovarian masses/ cysts smaller than 4 cms in
diameter
 Small fibroids and adenomyosis
 Hydrosalpinx diagnosis that could have resulted
from chronic PID
MRI rarely useful to diagnose adenomyosis
Best Pract Res Clin Obstet Gynaecol 2000 Jun;14(3):433-66
Laparoscopy in CPP
1/3 of laparoscopies are done for CPP
Findings are:
 No visible pathology 35%
 Endometriosis 33%
 Pelvic adhesions 24%
 PID 5%
 Ovarian cyst 3%
 Other diagnoses 5%
Tu FF; Beaumont JL Am J Obstet Gynecol. 2006 Mar;194(3):699- 703
Howard, FM. The role of laparoscopy in the chronic pelvic pain patient. Clin Obstet
Gynecol 2003; 46:749
Treatment of CPP
Treatment of pathology found
 Depression : cognitive-behavioral therapy
antidepressants
 Somatization: Psychotherapy

IBS: antidpressants, fiber, antispasmodics
 IC: bladder distension, antidepressants,
Pentosan polysulphate (Elmiron)

When do Gynecologists refer to pain
management
When the diagnosis of CPP syndrome is
made:
1- No etiology for pain is found in spite of a
comprehensive work-up
2- Treatment is completed but the patient is
still symptomatic
3- The severity or location of pain does not
match the pathology.
CONCLUSIONS
CPP is a symptom of many possible
conditions; work-up of the reproductive,
GU, GI and musculoskeletal systems may
be needed to reach a diagnosis.
 Check the patient’s previous w/up
particularly her previous surgeries
 KNOW your referring Gynecologist
 Beware of missing endometriosis, pelvic
adhesions IC and hernias!!
